Dental fear and anxiety is a common problem in pediatric patients. There is considerable variation in techniques used to manage them. Various sedation techniques using many different anesthetic agents have gained considerable popularity over the past few years. Children are not little adults; they differ physically, psychologically, and emotionally. The purpose of this review is to survey recent trends and concerning issues in the rapidly changing field of pediatric sedation. We will study the topic from the perspective of an anesthesiologist. It will also provide information to practitioners on the practice of conscious sedation in dentistry and will also outline the route of administration, pharmacokinetics, and pharmacodynamics of various drugs used.

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Background: The postdural puncture headache (PDPH) and postdural puncture backache (PDPB) are well-known complications of spinal anesthesia. There are some attempts to reduce the frequency of complication such as different design of the spinal needles. Aims: The primary outcome of this study is to compare the incidence of PDPH between 26-gauge Atraucan and 26-gauge Quincke spinal needles in elective cesarean operations. The severity of symptoms, the incidence of backache, technical issues, and comparison of cost of needles are secondary outcomes. Materials and Methods: After Investigational Review Board approval, a randomized, prospective, double-blinded study was designed in 682 American Society of Anesthesiologists I–II women having elective cesarean operations under spinal anesthesia. Patients were divided into two groups as 26-gauge Atraucan Group A (n = 323) and 26-gauge Quincke spinal needles Group Q (n = 342). All patients were questioned about backache 1 week later. Differences between categorical variables were evaluated with Chi-square test. Continuous variables were compared by Student's t-test for two independent groups. A two-sided P< 0.05 was considered statistically significant for all analyses. Results: There were no significant differences between groups in all demographic data. The one attempt success rate of the dural puncture in Group A (70,58%) and in Group Q (69.3%) was similar (P > 0.05). The incidence of PDPH was 6.5% in Group A and 4.9% in Group Q (P > 0.05). The epidural blood patch was performed to the three patients in Group A and five patients in Group Q who had severe headache (P > 0.05). The incidence of PDPB was 4.33% versus 2.04% in Group A and Group Q (P > 0.05). Conclusions: The incidence of complication rates and technical handling characteristics did not differ between two groups. Quincke needle is cheaper than Atracaun needle, so it can be a cost-effective choice in obstetric patients.

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Context: Postoperative sore throat (POST) is a complication that is unresolved in patients undergoing endotracheal intubation. Aim: To compare the effects of ketamine and magnesium sulfate nebulizations in two strengths, on the incidence and severity of POST, hoarseness, and cough. Settings and Design: Sixty surgical patients undergoing elective abdominal and lower limb surgeries under combined epidural and general anesthesia were included in this prospective, randomized, double-blinded study. Subjects and Methods: Patients in each group were nebulized with the respective study drug 15 min prior to the surgery, i.e., ketamine in Group K, magnesium sulfate 250 mg, and 500 mg in Group M1 and Group M2, respectively, and normal saline as control in Group C. A standardized anesthesia protocol was followed for all patients. After extubation, the patients were asked to grade POST, hoarseness, and cough at 0, 2, 4, 12, and 24 h. Statistical Analysis Used: One-way analysis of variance, Chi-square test, Fisher's exact test, paired t-tests, and Wilcoxon's signed-rank test as applicable. Results: Ketamine and magnesium sulfate 500 mg demonstrated a statistically significant decrease in POST at 0, 2, and 4 h, and postoperative hoarseness at 0 h. There was decrease in the incidence and severity of sore throat, hoarseness, and cough at all periods in the study groups as compared with control. Conclusion: Nebulization with ketamine 50 mg and magnesium sulfate 500 mg, 15 min before induction of general anesthesia and intubation, reduce the incidence and severity of POST and hoarseness of voice.

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Background: Obturator nerve (ON) stimulation during transurethral resection of lateral and posterolateral bladder wall tumor under spinal anesthesia may lead to obturator reflex, adductor contraction, and leg jerking with complications such as bleeding, bladder perforation, or incomplete tumor resection. Our study was carried out to obtain successful block of ON using ultrasound (US)-guided technique with or without nerve stimulation in patients undergoing transurethral resection of bladder tumor (TURBT) under spinal anesthesia. Aims: The aim of the study was to compare the effectiveness of two different techniques in blocking ON and adductor spasm during TURBT. Settings and Design: Prospective, randomized, double-blind study. Subjects and Methods: Sixty patients with American Society of Anesthesiologists Status II and III scheduled to undergo TURBT for lateral and posterolateral bladder wall tumor were enrolled. Group I (US group, n = 30) patients received 5 ml of bupivacaine 0.5% each at anterior, and posterior division of ON under real-time US visualization and Group II (US-NS group, n = 30) received the same amount of bupivacaine 0.5% for each division using US-guidance with nerve stimulation-assisted technique. Motor block onset time, block success and performance time, ease of performance of block, and complications were measured besides assessing patient and surgeon satisfaction into two groups. Statistical Methods Used: SPSS using two sample independent t-test and Pearson's Chi-square/Fisher's exact test. Results: Motor block onset was significantly faster in Group II (6.67 ± 2.40) than in Group I (12.39 ± 2.55). A success rate of 90% was achieved in Group II as compared to 76.7% in Group I with increased block performance time in Group II (4.47 ± 0.73 min) versus (2.10 ± 0.51 min) in Group I. A better patient and surgeon satisfaction were seen in Group II with combination of US and nerve stimulation technique. No complications were encountered. Conclusion: We conclude that both techniques are safe and easy to perform; however, nerve stimulation as an adjunct to US results in a faster onset of block with a higher success rate.

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We report a successful management of a case of methicillin-resistant Staphylococcus aureus positive right lower limb cellulitis for above knee amputation under combined nerve blocks. The ongoing sepsis, thrombocytopenia, and severe respiratory infection with wheeze made us avoid both neuraxial block and general anesthesia and plan for a nerve block. We instituted a modified high inguinal femoral block along with sciatic and lateral femoral nerve blocks separately to successfully conduct the case. We decided to report as there were not as many cases as ours in the literature.

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Background and Aims: Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia. This randomized, double-blind study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia. Methods: A total of sixty patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, group SD and group SN, including thirty patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg through spinal anesthesia. Group SD received injection dexamethasone 8 mg intravenously, and group SN received injection normal saline (NS) 2 cc immediately after spinal anesthesia. Duration of sensory block, motor block, postoperative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Whenever demanded rescue analgesia was given in the form of injection tramadol 100 mg. Results: The mean duration of sensory block (min) in group SD and group SN was 162.50 and 106.17, respectively which was highly significant. Similarly, time to the requirement of first rescue analgesia was prolonged in group SD (8.67 h) as compared to group SN (4.40 h). Significant changes were also seen in VAS score in postoperative period after 1 h of surgery in group SD and group SN. Duration of motor block, intra- and post-operative hemodynamic parameters were comparable in both the groups. No side effects were recorded in both the groups. Conclusion: We concluded that administration of dexamethasone 8 mg intravenously prolongs the duration of postoperative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.

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Background: Pain in the dental operatory can have a profound effect on the behavior of children. Aim: The aim of this study is to evaluate the pain perception while administering local infiltration, in children undergoing dental extractions, using a new auto-controlled injection system. Materials and Methods: Children in the age range of 6–10 years with teeth indicated for extraction were recruited and allocated to either Group I, computer-controlled injection system (auto system with special cartridge and compatible disposable 30-gauge, 10 mm needles), or Group II, traditional system (30-gauge, 10 mm needle and disposable traditional syringe). Local infiltration was administered and extraction performed after 3 min. The time of administration (TOA) of infiltrate was noted whereas anxiety and pain in both groups were assessed using the Modified Child Dental Anxiety Faces Scale simplified (MCDAS_(f)), pulse rate, Faces Pain Scale-Revised (FPS-R), and Face, Legs, Activity, Cry, Consolability (FLACC) Scale. Results: The TOA was high in computer group, compared to the traditional system (P < 0.001***); however, anxiety and pain were significantly less in computer group as reported in MCDAS_(f), pulse rate, FPS-R, and FLACC (P < 0.001***). Conclusions: Computer system created a positive and comfortable experience for the child, as well as the practitioner. The possibility of using buccal infiltration instead of inferior alveolar nerve block in children below 10 years was also demonstrated.

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Background: Millions of women worldwide undergo postpartum perineal repair under local infiltration. Inadequate postpartum pain management can negatively impact a mother's physical and psychological recovery. Aims: To study and compare the analgesic effect and maternal satisfaction with lignocaine versus ropivacaine infiltration for postpartum perineal pain relief. Materials and Methods: After clearance from the Institutional Ethics Committee, a double-blind prospective randomized study carried out on 100 parturients of aged 18–40 years who had spontaneous vaginal delivery, comparing 1% lignocaine and 0.75% ropivacaine infiltration for the repair of selective episiotomy or perineal injury. Time of the first analgesic (TFA) demand, maternal satisfaction at 24 h, and visual analog scale (VAS) pain score were studied. Statistical Analysis: Chi-square test and Student's t-test were used and P< 0.05 was considered as significant. Results: VAS pain score was significantly lower at 2 and 4 h in ropivacaine group versus lignocaine group (P < 0.0001). Significantly, longer TFA (10.2 ± 1.54 vs. 2.20 ± 0.44 h, P< 0.0001) and higher percentage of maternal satisfaction (86% vs. 44%) were observed in ropivacaine as compared to lignocaine group (P < 0.0001). Conclusions: Prolonged analgesia and higher rate of maternal satisfaction were found when ropivacaine infiltration was used for perineal repair as compared to lignocaine.

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Adults with congenital heart disease are increasing due to improvement in infant heart surgery and availability of better cardiac care. Pregnancy in these patients requires multidisciplinary team approach due to circulatory changes. We describe an anesthetic management of the parturient undergoing cesarean section having severe pulmonary restenosis.

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Introduction: Benefits of regional anesthesia can be prolonged by adding adjuvants to local anesthetics. This study was designed to test the efficacy of adding nalbuphine to bupivacaine in supraclavicular brachial plexus blockade using ultrasound (US) guidance. Methodology: This was a prospective, randomized, double-blind study involving sixty patients of either sex undergoing elective orthopedic procedures of upper limb. In control Group C (n = 30), 30 mL of 0.375% bupivacaine + 1 mL normal saline and in study Group N (n = 30), 30 mL of 0.375% bupivacaine + 1 mL (10 mg) nalbuphine were used for giving supraclavicular block under US guidance. Parameters assessed were onset and duration of sensory and motor block, duration of analgesia (DOA), and any adverse events. Data between the groups were analyzed using independent t-test with SPSS 16.0 software. Results: In Group N, there was a statistically significant shorter time to onset of sensory blockade (4.89 ± 1.5 vs. 14.62 ± 1.73 min, P = 0.000), longer duration of sensory block (373.17 ± 15.56 min vs. 157.82 ± 11.02 min, P = 0.000), shorter onset time to achieve motor block (8.83 ± 1.9 min vs. 18.76 ± 1.75 min, P = 0.000), longer duration of motor block (313.92 ± 16.22 min vs. 121.87 ± 16.62 min, P = 0.000), and prolonged analgesia (389.33 ± 14.52 min vs. 171.65 ± 19.79 min, P = 0.000). Conclusion: Nalbuphine when added to bupivacaine as an adjuvant in supraclavicular block significantly shortened the onset of sensory and motor block and enhanced the duration of sensory and motor block and DOA.

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Introduction: There is increasing evidence to include sedation as an integral part of regional anesthesia to ensure patient comfort. This may compromise patient cooperation, an important component of regional anesthesia. We decided to determine the efficacy of dexmedetomidine (0.3 μg/kg/h and 0.5 μg/kg/h) for allaying procedural discomfort and ensuring their cooperation in patients undergoing surgery with subarachnoid block. Setting: Tertiary care center. Materials and Methods: Sixty patients with the American Society of Anesthesiologists physical status Class I and II posted for surgeries under subarachnoid block were randomized into two groups of 30 each to receive dexmedetomidine in a loading dose of 1 μg/kg in both groups followed by continuous infusion of 0.3 μg/kg/h in Group D 0.3 and 0.5 μg/kg/h in Group D 0.5. Observer assessment sedation score, ease of positioning score, response to spinal needle insertion, hemodynamic parameters, patient satisfaction (PS) score, and surgeon satisfaction (SS) score were evaluated. Results: Median observer Assessment Sedation Score ranged between four and three at all times during dexmedetomidine infusion in Group D 0.3. In Group D 0.5, median Observer assessment of alertness/sedation scale ranged between three and two. Ease of positioning (P = 1.000) and response to spinal needle insertion (P = 0.521) were comparable in both groups. PS was higher in Group D 0.5 as compared to Group D 0.3. SS score was comparable in both the groups. Conclusion: Intravenous dexmedetomidine infusion 0.3 μg/kg/h produces effective sedation in patients undergoing surgery with spinal anesthesia while ensuring patient cooperation for positioning and without any recall of the procedure in postoperative period.

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Background: Preoperative medication has a vital role in anesthesia. Pregabalin (PG) is a newer drug of gabapentinoid class and is six times more potent than gabapentin. Our study was designed to evaluate the effect of PG as premedication on the perioperative anesthetic requirement and analgesia. Materials and Methods: The study was conducted on ninety patients of American Society of Anesthesiologists Grade I and II of age group 20–60 years, allocated to one of the three groups of thirty patients each. Group I received tablet diazepam 10 mg HS and 5 mg 1 h before surgery, Group II received capsule PG 75 mg HS and 150 mg 1 h before surgery, and Group III received capsule PG 75 mg HS and 300 mg 1 h before surgery. Patients were induced with injection fentanyl citrate, thiopentone sodium, and rocuronium bromide and maintained by 66% N₂O + 33% O₂gas mixture with sevoflurane and intermittent boluses of fentanyl. Results: Perioperative consumption of thiopentone sodium was 5.59 ± 0.49 mg/kg in Group I, 4.29 ± 0.53 mg/kg in Group II, and 4.06 ± 0.59 mg/kg in Group III; fentanyl was 1.55 ± 0.42 μg/kg in Group I, 1.00 ± 0.00 μg/kg in Group II, and 1.05 ± 0.20 μg/kg in Group III; sevoflurane (%) was 1.20 ± 0.31 in Group I, 0.933 ± 0.25 in Group II, and 1.00 ± 0.00 in Group III. Perioperative requirement of thiopentone sodium, opioid, and inhalational agent was significantly less in Group II and III when compared with Group I. Maximum number of patients required postoperative rescue analgesia within 0–2 h of surgery in Group I, 2–4 h of surgery in Group II, and 6–8 h after surgery in Group III. Patients were more comfortable and asleep with a longer pain-free postoperative period in PG groups. Conclusion: PG premedication effectively reduced the consumption of all anesthetic agents during induction and maintenance of anesthesia as compared to diazepam. Patient's postoperative comfort and pain-free duration were also greater with PG premedication; more so with PG 300 mg as compared to PG 150 mg.

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Background and Aims: Ultrasound-guided transversus abdominis plane (TAP) block has been proven as a safe and effective analgesic technique for several lower abdominal surgeries. Various adjuvants have been used to intensify the quality and prolong the local anesthetic effect. We evaluated the analgesic efficacy of dexamethasone addition to ropivacaine in TAP block following open abdominal hysterectomy. Materials and Methods: After clearance from the Institutional Ethics Committee, a double-blind, prospective, randomized study was carried out on sixty patients aged 40–60 years posted for elective open abdominal hysterectomy comparing bilateral TAP block using 20 ml of 0.5% ropivacaine + 1 ml of 0.9% saline (control Group R) or 20 ml of 0.5% ropivacaine + 4 mg dexamethasone (Group RD). The aim of our study was to observe postoperative pain score (visual analog scale [VAS]), time for first analgesic (TFA) demand, total analgesic consumption, and incidence of nausea or vomiting. Statistical Analysis: Chi-square test and Student's t-test were used, and P< 0.05 was considered as statistically significant. Results: Postoperative VAS pain scores were significantly lower at 4, 6, and 12 h in Group RD as compared to Group R (P < 0.05). Significantly longer TFA (13.2 ± 7.6 vs. 7.1 ± 4.6 h, P< 0.001) with lesser tramadol requirement in first 24 h (50.2 ± 34 vs. 94 ± 35 mg, P< 0.001) were observed in Group RD as compared to Group R. Incidence of nausea or vomiting was statistically insignificant between the groups (P > 0.05). Conclusions: Addition of dexamethasone to ropivacaine TAP block prolonged the postoperative analgesia and reduced analgesic requirement following abdominal hysterectomy.

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Background: The basic principle of neuroanesthesia is to provide hemodynamic stability, provision of optimal operative conditions, maintenance of cerebral perfusion pressure, and cerebral oxygenation. Aim: This study was undertaken to see the effect of dexmedetomidine infusion on hemodynamics and its ability to act as an anesthetic adjuvant in patients undergoing supratentorial tumor surgery. Setting and Design: Prospective randomized control double blind study. Subjects and Methods: In this study, we compared two groups with 25 patients in each group. Group C patients received saline infusion during surgery and 4 μg/kg of fentanyl intravenously (i.v.) at the induction and at pin head application. Group D patients received dexmedetomidine infusion during surgery at the rate of 0.4 μg/kg/h and 2 μg/kg of fentanyl i.v. at the induction and at pin head application Statistical Analyses Used: Parametric data were analyzed using Student's t-test. The categorical data were studied using Chi-squared test or Fisher's test as appropriate. Results: The vitals remained within 20% of baseline in both groups during the study period except at the time of extubation where the rise in heart rate was more than 20% in control group. The requirement of thiopentone for induction was significantly less in dexmedetomidine group. In dexmedetomidine group, less number of patients required intraoperative fentanyl (P < 0.05), and the time to rescue analgesic was also more in Group D (P < 0.05). Conclusion: Dexmedetomidine infusion started before surgery maintains hemodynamic stability intraoperatively and is effective in attenuating the cardiovascular responses to intubation, skull pin application, and extubation. It decreases the requirement of other anesthetic agents as well.

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Context: Regional anesthesia has emerged as one of the preferred and convenient modes for intra- and post-operative management owing to its advantage of not interfering with the metabolic functions, better tolerability, and decrease in reflex activity. In recent years, ropivacaine has increasingly replaced bupivacaine as a preferred local anesthetic because of its similar analgesic properties, lesser motor blockade, and decreased propensity of cardiotoxicity. Neuraxial adjuvant such as clonidine used in epidural anesthesia offers advantage by augmenting the local anesthetic effect and reducing the anesthetic and analgesic requirement. Aims and Objectives: Comparison of onset, duration of sensory and motor block, and any adverse effects between 0.5% ropivacaine with normal saline versus 0.5% ropivacaine with clonidine (75 μg/kg). Materials and Methods: This prospective randomized study was carried out in 50 patients (25 in each group) of American Society of Anesthesiologist Grade 1 and 2 scheduled for abdominal hysterectomy under epidural block. Group-1 (ropivacaine-clonidine [RC]): Epidural ropivacaine 20 ml (0.5%) with 0.75 μg/kg clonidine. Group-2 (ropivacaine [R]): Epidural ropivacaine 20 ml (0.5%) with normal saline. Onset, duration of sensory-motor block, heart rate, blood pressure, oxygen saturation, and respiratory rate were recorded. Statistical Analysis: The statistical analysis was done using Statistical Package for Social Sciences version 15.0. Chi-square test, ANOVA, Student's t-test, and paired t-test were used. Results: Groups were comparable with regard to demographic data and hemodynamic stability. Onset of sensory and motor blockade was faster in RC group as compared to R group. Duration of postoperative analgesia was significantly prolonged in RC group. No potential side effect was seen in either group. Conclusion: On account of faster onset, hemodynamic stability, and prolonged postoperative analgesia, ropivacaine with clonidine is a better option than ropivacaine alone.

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Background: Electroconvulsive therapy (ECT) is the most effective treatment available for the acute treatment of depression in patients who do not respond to medications. It is generally used as a second line treatment for many psychological disorders, mainly major depression and schizophrenia where medication is not effective. ECT is often associated with some complications such as hypertension, tachycardia arrhythmia and even myocardial infarction. Various methods have been used for prevention or control of these cardiovascular side effects. Aim: The aim of this study was evaluating the effect of oral clonidine (0.3 mg) with control group to know the effect of oral clonidine on hemodynamic response during ECT. Methods and Material: This prospective randomized crossover clinical trial was performed on 25 patients aged 20-50 years, weight 50-70 kg with ASA I and II who were candidates for ECT. Prior to ECT, each patient received oral doses of clonidine (0.3 mg) or a placebo 90 minutes before ECT. Baseline Heart rate, systolic, diastolic and mean arterial pressures were noted just before securing the intravenous cannula. The same parameters were noted after induction, immediately after seizure cessation following delivery of the electric shock and at 1 minute interval for 10 minutes. Statistical Analysis: Data was analyzed by ANOVA test (analysis of variance). P< 0.05 was considered statistically significant. Results: Attenuation of maximum rise in the heart rate and mean arterial pressure by clonidine (0.3 mg) was evident and statistically significant when compared with control group. Conclusion: Oral clonidine (0.3 mg) decreases the acute hypertensive response after electroconvulsive therapy; however, this antihypertensive effect was achieved by decreasing the blood pressure before the electrical stimulus.

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Background: Open surgical procedures are associated with substantial postoperative pain; an alternative method providing adequate pain relief with minimal side effects is very much required. Aim: The aim of this study was a comparative evaluation of the efficacy of continuous thoracic paravertebral block (PVB) and thoracic epidural analgesia (EA) for postoperative pain relief in patients undergoing open nephrectomy. Settings and Design: Prospective, randomized, and single-blind study. Materials and Methods: Sixty adult patients undergoing open nephrectomy under general anesthesia were randomized to receive a continuous thoracic epidural infusion (Group E) or continuous thoracic paravertebral infusion (Group P) with bupivacaine 0.1% with 1 μg/ml fentanyl at 7 ml/h; both infusions were started after induction of anesthesia. The primary outcome measures were postoperative pain during rest (static pain), deep inspiration, coughing, and movement (getting up from supine to sitting position); the secondary outcome measures were postoperative nausea and vomiting, requirement of rescue antiemetic, hypotension, sedation, pruritus, motor block, and respiratory depression. These were assessed till the morning of the third postoperative day. Statistical Analysis: Results were analyzed by the one-way ANOVA, Chi-square test, and Mann–Whitney U-test. P< 0.05 was considered significant. Results: Both the groups were similar with regard to demographic factors (P > 0.05). The visual analog scale scores at rest, deep breathing, coughing and movement, and postoperative fentanyl consumption were similar in the two groups (P > 0.05); the incidence of side effects was also similar in the two groups (P > 0.05). Conclusions: Continuous thoracic PVB is as effective as continuous thoracic EA in providing pain relief in patients undergoing open nephrectomy in the postoperative period. The side effect profile of the two techniques was also similar.

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Aim: The aim of the study was to evaluate the local anesthetic activity of root extracts of the Anacyclus pyrethrum, and to check its effect of interaction at the site of injection in guinea pigs. Materials and Methods: The study sample included thirty guinea pigs each weighing 450–500 g, maintained under standard conditions. The root extracts were prepared using three solvents, in 1% and 2% concentration and injected in guinea pigs. The animals were divided into five groups, six in each group based on the type of extract used along with a control and a standard drug. All the animals received 0.5 ml of intradermal injection of the prepared extract, with 1% concentration in the left and 2% in the right dorsal flank of the animal and were checked for local anesthetic activity by a pinprick test. After 72 h, biopsy was done from the injected site to check for drug interaction. Results: The number of negative response obtained from 2% ethanol extract is more effective when compared to other extracts. Histological samples showed inflammatory changes in 1% aqueous extract in a single animal. Conclusion: Among the test compounds, 2% ethanol showed more significant effect; hence, it is suggested to synthesize more compounds in this series and evaluate their pharmacological actions.

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Anaphylaxis during anesthesia is a life-threatening situation that occurs uncommonly. A 60-year-old woman with a history of anaphylaxis during previous anesthesia is scheduled to undergo elective open cholecystectomy. Her skin tests revealed sensitivity to vecuronium and nonsensitivity to injections of midazolam, fentanyl, and propofol. Due to high incidence of cross sensitivity among neuromuscular drugs, it was thought best to avoid general anesthesia. Spinal anesthesia was planned for the patient. The patient refused to give consent for spinal anesthesia, and she had to be taken up for surgery under general anesthesia. The only alternate neuromuscular blocking drug available to us was atracurium, which was tested for sensitivity by intradermal test. Atracurium was found to be not sensitive on intradermal test. We report here the dilemma and the challenges faced during management of general anesthesia in a patient with history of anaphylaxis to vecuronium.

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Background: Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. A survey reported that 40% of pediatric surgical patients experienced moderate or severe postoperative pain and that more than 75% had insufficient analgesia. Our study was carried to provide continuous infusion of intravenous (i.v.) tramadol alone using a dedicated infusion device Graseby 2100 syringe pump and compared it to a combination of i.v. tramadol infusion and per rectal paracetamol. Subjects and Methods: A total of 124 children aged 1–8 years selected for the study were randomized into two groups using a table of random numbers. Power calculation had suggested a sample size of 62 in each group with a power of 80% and significance level of 5%. Group A comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively. Group B comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively in addition to per rectal suppository of paracetamol in a dose of 90 mg/kg in 24 h (30 mg/kg as first dose followed by 20 mg/kg every 6 hourly for the next 18 h). Postoperatively, patients were observed for 24 h. Results: A statistically significant difference (P ≤ 0.001) in Face, Legs, Activity, Cry, Consolability pain scores was seen between two groups at 4, 6, and 8 h. Pain scores being less in Group B patients who had received infusion of tramadol and per rectal suppositories of paracetamol compared to Group A patients who received only infusion of tramadol. A statistically significant difference (P < 0.05) was found in mean analgesic consumption during the first 24 h between the groups. Consumption was more in Group A as compared to Group B. In Group A, 13 patients (21%) required rescue analgesia as compared to only 4 patients (6.5%) in Group B. Conclusion: We recommend use of an infusion of tramadol in a dose of 0.25 mg/kg/h in the first 24 h after surgery, in combination with a regular per rectal paracetamol in a daily dose of 90 mg/kg/day in four divided doses for children after major abdominal surgery. However, a close nursing supervision is essential to increase the safety profile.

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Background and Objectives: Anesthetic drugs and material wastage are common in operation rooms (ORs). In this era of escalating health-care expenditure, cost reduction strategies are highly relevant. The aim of this study was to assess the amount of daily intravenous anesthetic drug wastage from major ORs and to estimate its financial burden. Any preventive measures to minimize drug wastage are also looked for. Methods: It was a prospective study conducted at the major ORs of a tertiary care hospital after getting the Institutional Research Committee approval. The total amount of all drugs wasted at the end of a surgical day from each major OR was audited for five nonconsecutive weeks. Drug wasted includes the drugs leftover in the syringes unutilized and opened vials/ampoules. The total cost of the wasted drugs and average daily loss were estimated. Results: The drugs wasted in large quantities included propofol, thiopentone sodium, vecuronium, mephentermine, lignocaine, midazolam, atropine, succinylcholine, and atracurium in that order. The total cost of the wasted drugs during the study period was Rs. 59,631.49, and the average daily loss was Rs. 1987.67. The average daily cost of wasted drug was maximum for vecuronium (Rs. 699.93) followed by propofol (Rs. 662.26). Interpretation and Conclusions: Financial implications of anesthetic drug wastage can be significant. Propofol and vecuronium contributed maximum to the financial burden. Suggestions for preventive measures to minimize the wastage include education of staff and residents about the cost of drugs, emphasizing on the judicial use of costly drugs.

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Introduction: Preoperative evaluation of a patient is the fundamental component of anaesthetic practice. Inadequate documentation and record keeping on the preoperative evaluation form (PEF) can be a major obstacle to attaining good practice and improving patient outcomes following operative procedures. Aim: The aim of the study was to conduct an audit to assess the quality of the preoperative anaesthetic information gathered and to observe the quality profile after the introduction of a standardized pre-operative evaluation form. Study Design: This was a retrospective study, using a sample of 3000 files of patients who underwent elective surgery in a tertiary care hospital of rural India. We devised 11 quality indicators, looking at factors in the pre-operative, peri-operative and post-operative period, and used them to audit 3000 patient records in our Hospital. Results: We found several areas where quality could be significantly improved;last minute postponement/change of plan of planned surgeries has reduced from 134 (8.9%) to 23 (1.53%) cases after implementation of standardised PEF. 784 (52.26%) patients were not formally handed over to the theatre recovery staff before implementation of standardised PEF compared to 147(9.8%) after implementation of standardised PEF. Conclusion: This audit found several areas of practice that fall below expected standards before the introduction of standardised PEF, but after the introduction of standardised PEF there is a significant improvement in quality of pre anaesthetic evaluation and overall outcome of the patient. We therefore advocate the use of such standardised PEFs for performing preoperative and perioperative assessment of surgical patients.

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Background: Radical prostatectomy is a major surgical procedure that is associated with marked inflammatory response and impairment of the immune system which may affect the postoperative outcome. The aim of this study was to evaluate the effect of preincision single or multiple doses of S(+) ketamine on the pro-inflammatory cytokines, namely tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Patients and Methods: This is a randomized controlled trial including 60 American Society of Anesthesiologists Physical Status I and II patients scheduled for radical prostatectomy under combined general-epidural anesthesia in Cairo university Teaching Hospital. Patients were randomly divided into three groups each of twenty patients: Group I received no S(+) ketamine (control group), Group II received S(+) ketamine as a single preincision dose, and Group III received preincision and repeated doses of S(+) ketamine. S(+) ketamine was injected as a single intravenous dose of 0.5 mg/kg in Group II and III, repeated as 0.2 mg/kg at 20 min interval until 30 min before the end of surgery. Results: The three groups were comparable in age, weight, and duration of the operation. The study also revealed that a single preincision dose of S(+) ketamine decreased TNF-α to reach 1027.04 ± 50.13 μ/ml and IL-6 to reach 506.89 ± 25.35 pg/ml whereas the repeated doses of S(+) ketamine decreased TNF-α to reach 905.64 ± 35065 μ/ml and IL-6 to reach 412.79 ± 16.5 pg/ml (P < 0.05). Conclusion: S(+) ketamine suppresses pro-inflammatory cytokine production, especially when given in repeated doses.

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We describe a case of a 17-year-old male who remained drowsy following left temporomandibular joint (TMJ) interposition arthroplasty for TMJ ankylosis. Computed tomography of the head demonstrated an extradural hematoma. The possible cause of this unusual occurrence is discussed.

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Introduction: Anesthesia and surgery have proved to be highly anxiety provoking and with the rise of elective surgery, its aspect of patient's experience has become prominent in time. However, our fault as anesthesiologists is that we have not made people get versed with what we people as anesthesiologist do in the operating room. Hence, keeping in view all this, a study was carried out, in which video information/images regarding anesthesia and surgical procedure was shown to patients on PowerPoint Presentation. Different images showing previous patient's hospital journey were shown to educate patients. Methods: Two hundred patients scheduled to undergo elective surgery were taken and were divided into two groups of 100 each. Patients (study group or Group I) were shown video clippings/images of other previously operated patients and their hospital journey including surgery and anesthesia for which patient came in hospital. The study was carried out on the patient in each group while Group II was treated in normal way and not shown any type of images/videos. Hamilton Anxiety Rating Scale was used as a criterion to measure the level of anxiety in Group I and II at four different intervals that are before pre anesthetic check up (PAC), after showing videos and images in Group I, 1 h before surgery and 8 h after surgery. Statistical Analysis: The results of observation of both the groups at different intervals time were statistically compared and analyzed. These characteristics were analyzed using the “Chi-square tests” and “unpaired t-test.” Results: Video and images information if done preoperatively have been shown to reduce patient's anxiety, although little is known regarding the effects of the method. Conclusion: Showing videos/images of hospital journey for educating the patients before the operation is beneficial to patients undergoing elective surgery.

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Background and Aims: Elective lower segment cesarean section under spinal anesthesia is frequently associated with shivering. Ondansetron has been shown to be effective for postspinal shivering. In the present study, we compare the efficacy of ondansetron to prevent postspinal shivering in parturients undergoing cesarean delivery under spinal anesthesia. Materials and Methods: A total of eighty full-term parturients scheduled for elective lower segment cesarean section under spinal anesthesia were randomly allocated into two groups. Group O received 8 mg/4 ml ondansetron, and Group S received 4 ml normal saline intravenously immediately before induction of spinal anesthesia. The level of sensory block, core body temperature, shivering score, and presence or absence of nausea and vomiting during the perioperative period, 1^st and 5^th min neonates Apgar scores were recorded. The data analysis was carried out with Z-test and Chi-square test. Results: Ten percent (4/40) of patients in Group O and 42.5% (17/40) of patients in Group S had Grade III shivering during the perioperative period and that was treated with intravenous injection tramadol (P = 0.001). Two patients (5%) in ondansetron and 19 patients (47.5%) in control group had nausea and vomiting (P < 0.001) and was treated with intravenous 10 mg metoclopramide. 1^st and 5^th min Apgar scores of neonates were not statistically different in the groups. Conclusions: Ondansetron is an effective way to prevent shivering, nausea and vomiting during lower segment cesarean section under spinal anesthesia with no effect on Apgar score.

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Aim: The aim of this study is to compare the ultrasound estimation of the cross-sectional area (CSA) and diameter of internal jugular vein (IJV) with left ventricular end diastolic area (LVEDA) for the assessment of intravascular volume in pediatric patients during cardiac surgery. Patients and Methods: The CSA and diameter of the left IJV were defined, using ultrasound machine, and compared with LVEDA, estimated by transesophageal echo, in four times intervals (immediately after induction [T1], before the start of cardiopulmonary bypass [CPB] [T2], immediately after weaning of CPB [T3], and at the end of surgery before transfer to the Intensive Care Unit [T4]) as a tool for intravascular volume assessment in 16 pediatric patients undergoing cardiac surgery. Results: There was a poor correlation between IJV CSA and diameter with LVEDA. r values were 0.158, 0.265, 0.449, and 0.201 at the four time intervals (T1, T2, T3, and T4), respectively. Conclusion: Estimation of the CSA and diameter of the left IJV using ultrasound is not reliable and cannot be used alone to decide further management.

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Background: Peripheral nerve blocks have become an increasingly popular form of anesthesia. Preemptive analgesia reduces central sensitization, postoperative pain, and analgesic consumption. Different additive has been used to prolong regional blockade and improve postoperative analgesia. Aim: This study was conducted to evaluate whether preemptive ankle block using combination of ropivacaine and dexamethasone would succeed in improving the postoperative analgesia after foot surgery in patients receiving general anesthesia. Study Design: Randomized double-blind clinical trial. Patients and Methods: The study was done on forty American Society of Anesthesiologists physical Status I and II, patients undergoing elective forefoot and midfoot surgery under general anesthesia after written informed consent and Ethical Committee approval, general anesthesia was induced as usual, the patients were breathing spontaneously, laryngeal mask airway was inserted, and anesthesia was maintained using inhalational anesthetic. Ankle block was performed before surgery using 20 ml containing 18 ml ropivacaine 0.75% and 2 ml containing 8 mg dexamethasone in Group I and 20 ml containing 18 ropivacaine 0.75% plus 2 ml normal saline in Group II. Evaluation of ankle block was performed by testing the motor response to electric nerve stimulation of both the posterior tibial nerve and the deep peroneal nerve. The absence of any motor responses indicated success of the block. Surgery was started in 30 min after the block. After recovery from anesthesia, the following was measured, visual analog score at 1, 4, 6, 12, and 24 h, the time to the first rescue analgesic, the analgesic requirements, and any side effects. Statistical Analysis: Data were presented as means (standard deviation). Mann–Whitney U-test were used for continuous data. Student's t-test was used for normal distributed data. Results: Patients were similar as regard to demographic data, type, and duration of surgery. Pain intensity was significantly lower in dexamethasone group (P < 0.05). Time to first rescue analgesic was prolonged in dexamethasone group (110 ± 3.3 min vs. 66 ± 7.9 min; P = 0.001) The analgesic consumption was significantly lower in dexamethasone group. The complication was minor and self-controlled in both groups. Conclusion: The addition of dexamethasone to ropivacaine improved preemptive ankle block analgesia by decreasing postoperative pain intensity and analgesic consumption with minimal postoperative complication.

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Background: Lumbar spine surgery demands intense analgesia. Preemptive multimodal analgesia (MMA) is a novel approach to attenuate the stress response to surgical stimulus. Aims: The aim of the study was to assess the intraoperative morphine consumption in patients undergoing lumbar spine surgery. Patients and Methods: A randomized, prospective, double-blind study involving 42 patients belonging to the American Society of Anesthesiologists Class I and II scheduled to undergo elective lumbar spine surgery were allocated into two groups of 21 each. Group A (study group) received injection diclofenac sodium, paracetamol, clonidine, and skin infiltration with bupivacaine adrenaline and Group B (control group) received paracetamol and skin infiltration with saline adrenaline. Preemptive analgesia was practiced in both the groups. Intraoperative morphine consumption was documented. Statistical Methods: Intraoperative morphine consumption between the two groups was compared using Mann–Whitney U-test. Postextubation sedation score between the two groups was compared using Chi-square test and presented as number and percentage. P < 5% was considered statistically significant. Results: Intraoperative morphine consumption was significantly low in the study group (P < 0.001). Postextubation sedation score was comparable between the two groups. Conclusion: Preemptive MMA has demonstrated significant morphine sparing effect intraoperatively in patients undergoing lumbar spine surgeries.

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Context: Awareness under anesthesia is a rare but extremely unpleasant phenomenon. There are very few studies in the developing world and none from rural areas where incidence of intraoperative awareness may be higher due to increased patient load, limited patient knowledge and lack of trained hospital staff, reliance on older, cheaper but less effective drugs, and lack of proper equipment both for providing anesthesia, as well as monitoring the patient. Aims: To assess the incidence of intraoperative awareness during general anesthesia among patients in rural India and any factors associated with the same. Settings and Design: Prospective, nonrandomized, observational study. Subjects and Methods: Patients undergoing elective surgical procedures in various specialties under general anesthesia from over a period of 1 year were considered for this study. Approximately, after 1 h of arrival in postanaesthesia care unit, anesthesiologist (not involved in administering anesthesia) assessed intraoperative awareness using a modified form of Brice questionnaire. Statistical Analysis Used: Data were collected on a Microsoft Excel^® sheet and analyzed using Statistical Package for the Social Sciences^® version 23 (SPSS Inc., Chicago, IL, USA) for windows. Results: A total of 896 patients completed the questionnaire. Postoperatively, in response to the questionnaire, seven patients reported to have remembered something under anesthesia. Out of these, three patients described events that were confirmed by operation theater staff to have occurred whereas they were under anesthesia. Conclusions: Incidence of definite awareness under anesthesia with postoperative recall was found to be 0.33% (three patients out of total 896) in our study.

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Background: Preemptive analgesia is a part of multimodal regime for effective postoperative analgesia. Ketamine is said to possess preemptive effects, which has been simultaneously refuted by other studies. Hence, we designed this randomized, double-blinded trial to establish the influence of timing of perioperative ketamine administration for superior postoperative analgesia. Methods: Ninety patients undergoing infraumbilical surgeries under spinal anesthesia were randomized to receive ketamine either preincision (Group KI), preincision and during skin closure (Group KII), or only during skin closure (Group KIII). Outcomes studied were postoperative pain, sedation, and incidence of side effects. Results: Analysis of variance statistics for postoperative visual analog scales (VAS) for pain showed no significant difference in three groups. However, there was a significant difference between Groups KII and KIII in the immediate postoperative period (95% confidence interval [CI] of mean VAS for Group KI = 0.9249–1.4889; 95% CI for Group KII = 1.4406–1.8260; P = 0.043). Sedation scores in the immediate, 4 h and 8 h postoperative showed a significant difference between Group KI and Group KII (P = 0.007, 0.008, 0.001, respectively) and between Group KI and KIII (KI: KIII - P = 0.0008, 0.0006, 0.02, respectively). Although the incidence of psychotomimetic effect was more in Groups KIII, it was not statistically significant. Conclusion: Ketamine possesses postoperative analgesic effects in the immediate postoperative period only when its preemptive administration is supplemented with repeat administration during closure. Incidences of side effects were comparable in all groups.

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Introduction: Postoperative period after panhysterectomy is very painful as there is too much tissue handling. In the practice of regional anesthesia neuraxial, opioids have been used extensively as an adjuvant to bupivacaine to enhance the potency and duration of sensory and motor block produced by bupivacaine with satisfactory results. However, delayed respiratory depression by opioids has prompted further research to develop nonopioid analgesics. This study was undertaken to assess the degree of sensory and motor block and postoperative analgesia provided by low dose 50 μg intrathecal clonidine admixed with 0.5% hyperbaric bupivacaine as compared to bupivacaine alone in patients undergoing a total abdominal hysterectomy. Materials and Methods: Hundred adult patients of American Society of Anesthesiologist Class 1 and 2 were randomly allocated to Group A and Group B. Group A patients received 15 mg 0.5% hyperbaric bupivacaine with 50 μg clonidine intrathecally. Group B patients received 15 mg 0.5% hyperbaric bupivacaine with normal saline. Observation and Results: The mean duration of motor block was significantly higher in Group A (270.80± 66.0 min) as compared to Group B (184.60 ± 72.03 min), with statistically significant difference. There was also statistically significant difference in the duration of sensory block between Group A (290.20 ± 80.27 min) and Group B (190.83 ± 86.90 min). The duration of postoperative analgesia was significantly higher in Group A as compared to Group B (541.06 ± 130.64 min and 252.80 ± 84.10 min respectively). Conclusion: Addition of intrathecal clonidine 50 μg to bupivacaine (15 mg, 0.5%) prolongs the duration of sensory and motor block and duration of analgesia, thus produces an effective spinal anesthesia and good postoperative analgesia for longer duration and reduced postoperative analgesic requirement.

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Background: The needle puncture produces discomfort during regional anesthesia. Sedation and local anesthesia are used to promote analgesia and amnesia. The main objective of this study was to compare the efficacy of four subanesthetic doses of dextroketamine for pain relief during brachial plexus block via the posterior approach. Materials and Methods: Patients American Society of Anesthesiology I and II programed for elective surgery under brachial plexus block were distributed at randomized into four groups of twenty patients. Group A received dextroketamine 0.1 mg/kg, Group B received dextroketamine 0.15 mg/kg, Group C received dextroketamine 0.2 mg/kg, and Group D received dextroketamine 0.25 mg/kg. Sedation, facility to positioning, reaction to pinprick, nystagmus, hallucination, tachycardia, elevation of systolic blood pressure or cardiac rate, reduction in SpO₂ (<96%), apnea, airway obstruction, collateral effects, and patient satisfaction were monitored. Results: There is a positive correlation between increasing dose of ketamine and the degree of sedation and easiness to position the patient on the table. There exists a negative correlation associated between increasing the dose of ketamine and the response to pinprick, as also to the incidence of hallucination. Conclusion: Dextroketamine in doses of 0.1 mg/kg provide sufficient sedation to maintain the patient in position for brachial plexus block and for the relief of pain in 55% of them during the procedure, without hemodynamic variation. The pain relief and collateral effects are dose-dependent.

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Aim: The aim of this study was to determine intraoperative sedative and perioperative analgesic requirement and associated side effects of pregabalin (150 mg) for monitored anesthesia care during ear-nose-throat (ENT) surgeries. Materials and Methods: The study design was randomized and single-blinded; fifty patients undergoing elective ambulatory ENT surgeries under monitored anesthesia care were randomly allocated to receive either placebo (Group P) or pregabalin (Group PG) 150 mg, orally 1 h before surgery. All patients were then given intravenous (i.v.) midazolam 2 mg and fentanyl 1 μg/kg and local anesthesia at the site. Sedation was induced by administering an i.v. bolus of propofol 0.8 mg/kg and was maintained by continuous infusion of propofol. Level of sedation was assessed by Ramsay scale, and propofol infusion was titrated accordingly. Intraoperative pain was assessed by verbal rating scale (VRS) score. Patient having VRS >4 or complaint of pain was given fentanyl (0.5 μg/kg) i.v. bolus. Intraoperative sedative and analgesic requirement were recorded. Postoperative visual analog scale scores and requirement of analgesics were recorded for the first 24 h after surgery. Diclofenac 75 mg intramuscular (i.m.) was administered as rescue analgesic. Side effects (nausea/vomiting, sedation, dizziness, blurred vision) were also recorded. Results: Intraoperative propofol (212 ± 11 mg vs. 174 ± 9 mg; P = 0.013) and fentanyl (120 ± 8 μg vs. 94 ± 6 μg; P = 0.02) consumption was significantly lower in Group PG. Time to first analgesic request was longer (6.1 ± 0.4 h vs. 9.5 ± 1.2 h) with lesser requirement of analgesics (diclofenac) in the postoperative period. Incidence of side effects (sedation, nausea, vomiting) was found to be similar in both the groups. Conclusion: Premedication with pregabalin (150 mg) reduces intraoperative sedative and perioperative analgesic requirement in patients undergoing ENT surgeries under monitored anesthesia care with tolerable side effects.

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Background and Aims: Laryngoscopy and endotracheal intubation are associated with reflex sympathetic stimulation, known as pressor response and can cause major complications. We compared the attenuating effect of time-tested lignocaine versus clonidine on the hemodynamic response to laryngoscopy and intubation in neurosurgical cases. Design: A prospective, randomized, comparative, double-blind study with a sample size of sixty patients. Methods: Sixty patients undergoing elective neurosurgery were randomly allocated into one of the two groups: Group L (n = 30) received lignocaine 1.5 mg/kg intravenous (i.v.) before induction and Group C (n = 30) received clonidine 2 μg/kg i.v. before induction. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at baseline, after drug, after induction and 1, 2, 3,5,10, and 15 min after intubation. Statistical Analysis: Statistical software, namely, SPSS, version 15.0 by SPSS Inc., Chicago, USA was used for the analysis of data with Chi-square test to compare intergroup hemodynamic parameters. Results: Mean HR remained above baseline at all times after intubation in lignocaine group but decreased at 2 min after intubation and remained below baseline at all times in the clonidine group. SBP, DBP, and MAP all increased above baseline at 1 min after intubation in lignocaine group, and decreased below baseline at 2 min after intubation, whereas in the clonidine group they all decreased below baseline after drug administration and remained below baseline at all times. Therefore, clonidine is very effective in attenuating pressor responses and this difference between the groups is statistically very significant with P< 0.001. Conclusion: Clonidine is more effective than lignocaine for attenuating the pressor responses to laryngoscopy and endotracheal intubation in neurosurgical cases.

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Background: Lumbar spine surgery is associated with hemodynamic variations at intubation, change of position, and skin incision. A balanced anesthesia with multimodal analgesia (MMA) is necessary to attenuate these changes. Aim: To assess the relative effectiveness of preemptive MMA compared with the conventional analgesic regime in suppressing the hemodynamic response to endotracheal intubation, prone positioning, and skin incision. Settings and Design: A randomized, prospective study involving 42 patients belonging to the American Society of Anesthesiologists Physical Status 1 and II scheduled to undergo elective lumbar spine surgery were allocated into two groups of 21 each. Materials and Methods: Forty-two patients were randomly allocated into Groups A and B. Group A (study group) received diclofenac, paracetamol, clonidine, and bupivacaine with adrenaline skin infiltration and Group B (control group) injection paracetamol and saline with adrenaline skin infiltration. Statistical Analysis Used: Hemodynamic parameters (heart rate [HR], systolic blood pressure [SBP], diastolic blood pressure [DBP], and mean arterial pressure [MAP]) between the groups following intubation, prone position, and skin incision were noted and compared using repeated measure analysis of variance. One sample t-test was used to compare the standard mean concentration with the means of the study and control groups. P< 5% being considered statistically significant. Results: In the study group, HR, SBP, DBP, and MAP were lower at intubation and change of position as compared to the control group and were statistically significant. Conclusion: Preemptive MMA with balanced anesthesia is effective in attenuating the hemodynamic responses to multiple noxious stimuli during lumbar spine surgery.

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Introduction: Brachial plexus blockade is a time-tested technique for upper limb surgeries. The classical approach using paresthesia technique is a blind technique and may be associated with a higher failure rate and injury to the nerves and surrounding structures. To avoid some of these problems, use of peripheral nerve stimulator and ultrasound techniques were started which allowed better localization of the nerve/plexus. Ultrasound for supraclavicular brachial plexus block has improved the success rate of the block with excellent localization as well as improved safety margin. Hence, this study was planned for comparing the efficacy of conventional supraclavicular brachial plexus block with ultrasound-guided technique. Subjects and Methods: After obtaining the Institutional ethical committee approval and patient consent total of 60 patients were enrolled in this prospective randomized study and were randomly divided into two groups: US (Group US) and C (Group C). Both groups received 0.5% bupivacaine. The amount of local anesthetic injected calculated according to the body weight and was not crossing the toxic dosage (injection bupivacaine 2 mg/kg). The parameters compared between the two groups were lock execution time, time of onset of sensory and motor block, quality of sensory and motor block success rates were noted. The failed blocks were supplemented with general anesthesia. Results: Demographic data were comparable in both groups. The mean time taken for the procedure to administer a block by eliciting paresthesia is less compared to ultrasound, and it was statistically significant. The mean time of onset of motor block, sensory blockade, the duration of sensory and motor blockade was not statistically significant. The success rate of the block is more in ultrasound group than conventional group which was not clinically significant. The incidence of complications was seen more in conventional method. Conclusion: Ultrasound guidance is the safe and effective method for the supraclavicular brachial plexus block. Incidence of complications are less as ultrasound provides real-time visulaization of underlying structures and the spread of local anaesthetic.

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Use of sedation in patients with obstructive sleep apnea (OSA) in dentistry is limited. Hypoxia may develop during medication sleep in dental patients with OSA because of repetitive partial or complete obstruction of the upper airway. In this regard, anesthesiologists prefer not to give any sedative to surgical patients with OSA or support the use of general anesthesia due to good airway control. We report a case where we could successfully sedate a dental patient with OSA using intraoperative continuous positive airway pressure (CPAP) without hypoxia. Use of sedation and intraoperative CPAP in patients with OSA may be considered only if the effectiveness at home CPAP therapy is proven.

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Background: Epidural administrations of α2 agonists are being used as adjuvants as they lead to anxiolysis, sedation, analgesia, and hypnosis. Aim: This study aims to evaluate the analgesic effects of epidural α2 agonists-dexmedetomidine and clonidine in conjunction with intrathecal levobupivacaine in combined spinal epidural anesthesia (CSEA). Methods: A prospective, randomized controlled study was done to assess and compare the efficacy and clinical profile of two α2 adrenergic agonists, clonidine, and dexmedetomidine administered epidurally in combination with intrathecal levobupivacaine in CSEA. The study was conducted for 1 year. Sixty adult patients physical status Class I and II undergoing below umbilical surgeries under CSEA were included in the study after a valid consent. Patients were randomly assigned into two groups, to receive either epidural dexmedetomidine (1.5 μg/kg) or clonidine (2 μg/kg) in 10 ml normal saline along with 0.5% isobaric levobupivacaine 15 mg (3 ml). Block characteristics, ability to provide sedation, duration, and quality of analgesia and side effects were studied and compared between the groups. Results: The characteristics of intraoperative block were comparable among two groups. As compared to clonidine, dexmedetomidine provided a better sedation and prolonged analgesia, evidenced by the distribution of visual analog scale scores and requirement rescue analgesic among two groups. The side effect profile of the two drugs was comparable. Conclusion: Dexmedetomidine at 1.5 μg/kg epidurally with intrathecal levobupivacaine is a better adjuvant compared to clonidine at 2 μg/kg epidurally in CSEA because of better sedation, prolonged analgesia, and safe side-effect profile.

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Background: Preoperative anxiety may lead to peroperative or postoperative problems when not overcome. Aims: The aim of this study was to examine the effect of seeking information and other factors on the anxiety of patients preoperatively. Settings and Design: This study was a prospective, multicentered survey. Materials and Methods: Patients scheduled to undergo surgical procedures under spinal anesthesia, preoperatively evaluated as the American Society of Anesthesia 1–3 and where spinal anesthesia was agreed on beforehand, were included. Patients completed State-Trait Anxiety Inventory Scale-State (STAI-S) survey preoperatively. Patients who sought information were also asked to complete the Amsterdam Preoperative Anxiety and Information Scale survey. Statistical Analysis: Quantitative data were compared with one-way ANOVA with post hoc analysis or Kruskal–Wallis test. Comparison of two groups of parameters showing normal distribution was compared using Student's t-test. Comparison of groups versus anxiety was performed using Chi-square and Fisher's exact tests. Results: A total of 330 patients were included. Average STAI-S scores were similar when evaluated for patients' demographic data, gender, marital status, place of residence, type of operation, preoperative fasting time, and comorbidities. University graduates were found to have lower anxiety when compared to other educational statuses. Seeking information from the internet caused a significant decrease in surgical anxiety (P < 0.05) although it had no effect on anesthesia-related anxiety. Interestingly, those seeking information had higher information desire levels compared to patients who had not sought other sources of information (P < 0.05). Conclusion: While patients seeking information regarding surgical procedure and/or spinal anesthesia have lower preoperative anxiety levels, their information desire remains high. Apart from detailed information given by the anesthesiologist or surgeon, having access to correct and validated information in multimedia form may decrease anxiety and information desire.

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Background: Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO₄ pretreatment is good options. Aims: To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. Settings and Design: A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. Materials and Methods: After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18–60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40–70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Statistical Analysis Used: Chi-square test and independent t-test were done with PASW statistics 18 to analyze data. Results: The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s (P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups (P = 0.791). Hemodynamic parameters were comparable between groups at all time frames (P > 0.05). Conclusion: Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation.

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Background: Ketamine, in low doses, is known to possess intense analgesic properties. The available literature shows wide variation regarding the time and dose of administration of ketamine during surgery. Aim: The aim of this study was to evaluate the effect of intraoperative administration of ketamine when used as sole analgesic in low doses, on hemodynamics and postoperative analgesia in patients undergoing laparoscopic gynecological surgery and compared on the basis of duration of surgery. Settings and Design: This prospective, observational study was conducted from July to December 2015, over a period of 6 months in a tertiary care medical college and hospital. Materials and Methods: Seventy patients between 23 and 55 years planned for laparoscopic gynecological surgery were recruited. Ketamine was given in a dose of 0.5 mg/kg preoperatively and then repeated every ½ hourly in a dose of 0.25 mg/kg throughout the surgery. Hemodynamic parameters, time to the first rescue analgesia and complications were recorded for the first 8 h. Statistical evaluation was done and result expressed as percentage. Paired t-test was employed for the comparison of numerical variables within the group. Results: Seventy percent of the patients did not require any postoperative rescue analgesia during the first 8 h after surgery. None of the patients complained of pain immediately after extubation, and 16% of the patients had minor postoperative complications. The intraoperative hemodynamic profile was significantly altered. Duration of surgery and dose of ketamine required did not affect the duration of analgesia. Conclusion: Ketamine in low dose proved to be an efficacious analgesic even in the long duration laparoscopic gynecological surgeries. It stabilizes intraoperative hemodynamics thereby reducing the requirement of other anesthetic and antihypertensive agents.

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Aims and Objectives: The aim of this study is to compare the effects of intrathecal levobupivacaine with levobupivacaine and fentanyl in patients undergoing cesarean section. Methods: Patients with American Society of Anesthesiologists Physical Status I and II scheduled for cesarean section under spinal anesthesia were randomly allocated with thirty patients each. Group L: levobupivacaine group – thirty patients (10 mg). Group F: levobupivacaine plus fentanyl group – thirty patients (7.5 mg + 12.5 μg). Hemodynamic monitoring, sensory and motor levels, and neonatal Apgar score were noted intraoperatively. The total duration of motor and sensory block, time for rescue analgesia was noted postoperatively. Results: Prolonged duration of postoperative sensory and rescue analgesia was found in Group F – 112.97 ± 19.42, 231.26 ± 10.92 min as compared to Group L – 100.37 ± 10.64, 185.93 ± 11.09 min and duration of motor blockade was prolonged in Group L – 87.83 ± 15.04 min than Group F – 79.20 ± 8.93 min and P< 0.05 was found statistically significant. Apgar scores in both groups were comparable. Conclusion: Intrathecal levobupivacaine plus fentanyl prolonged duration of sensory block and rescue analgesia without prolonging motor block which could help in early ambulation.

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Background: The challenge in providing analgesia for spine surgeries is to provide extended postoperative pain relief and simultaneously allow early neurological assessment and mobilization. Our study aimed to evaluate the analgesic efficacy of intravenous versus caudal dexamethasone in lumbosacral spine surgeries. Materials and Methods: In this prospective double-blind study, a total of 96 patients undergoing lumbosacral spine surgery were randomized into three groups to receive 25 ml of preemptive caudal epidural injection of either injection ropivacaine 0.2% (Group A, n = 32), a 25 ml of injection ropivacaine 0.2%, and intravenous injection dexamethasone 8 mg (Group B, n = 32) or 25 ml mixture of injection ropivacaine 0.2% with injection dexamethasone 8 mg (Group C, n = 32) under general anesthesia. Visual analog scale (VAS), heart rate, blood pressures, blood sugar levels, and time to rescue analgesia were recorded at regular intervals for the first 24 h. Time to discharge was noted. Analysis of variance has been used to find the significance of study parameters between the groups of patients. Statistical software, namely, SAS 9.2 and SPSS 15.0, have been used for the analysis of the data. Results: The mean VAS was significantly lower in the Group C for up to 24 h following the caudal block. No significant hemodynamic changes were noted in any of the groups. The intravenous dexamethasone group showed higher blood glucose levels at 24 h but was not clinically relevant Conclusion: These results suggest that injection dexamethasone is a safe adjunct to caudal ropivacaine in lumbosacral spine surgeries.

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Background: Women undergoing cesarean (CS) delivery present a unique set of challenges to the anesthetist in terms of postoperative pain management. This study was conducted to compare the analgesic efficacy of intrathecal buprenorphine (ITB) with ultrasound-guided transversus abdominis plane (TAP) block in post-CS delivery pain. Methodology: A prospective randomized comparative study of sixty American Society of Anesthesiologists physical status I and II pregnant patients divided into two groups of thirty each as ITB group and TAP block group after satisfying the inclusion criteria. Results: In the present study, demographic data were comparable between both groups. The time to first analgesic request was significantly longer in ITB group (389.67 ± 90.78 min) compared to TAP group (669.17 ± 140.65 min) and was statistically significant, P< 0.001. The mean paracetamol consumption in the first 24 h was higher in the TAP group (3.5 g) compared to the ITB group (1.13 g) and was statistically significant, P< 0.0001, and the mean tramadol consumed in first 24 h was higher in the TAP (46.66 mg) group as compared to the ITB group (16.66 mg) and was statistically significant, P< 0.001. The mean visual analog scale scores assessed at 4, 6, 12, and 24 h was higher in the TAP group and was statistically significant, P< 0.001. Conclusions: Our study showed that patients receiving ITB for post-CS pain management reported longer duration of analgesia, lower pain scores, and lower analgesic consumption during the first 24 h. The benefits of neuraxial opiates are significant and far outweigh the side effects.

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Background: Oxygen supplementation through Hudson type face mask is frequently used in perioperative settings. Hudson mask is a variable rate performance device with the risk of rebreathing. Studies using capnography to find out an actual fraction of rebreathing in spontaneously breathing patients are not available. Aims: In this study, we analyzed the effects of different flow rates through Hudson mask with capnography on fractional inspired carbon dioxide (FiCO₂). Setting and Designs: Forty patients posted for minor surgeries under monitored anesthesia care were divided into four groups. They received oxygen flow rate of 3 L/min, 4 L/min, 5 L/min, and 6 L/min as per group division, through Hudson mask. Materials and Methods: Parameters such as pulse rate, noninvasive blood pressure, oxygen saturation, respiratory rate (RR), end-tidal carbon dioxide (EtCO₂), and FiCO₂ were noted at baseline. After starting oxygen supplementation, these parameters were monitored every minute for ten minutes. Statistical analysis was done using analysis of variance and Kruskal–Wallis test. Pearson correlation was used to establish a relation between RR and FiCO₂. Results and Conclusions: EtCO₂ and FiCO₂ were comparable in all four groups with no statistical significance. There was strong positive correlation seen between RR and FiCO₂ at a flow rate of 3 L/min while negative correlation in other groups. We conclude that FiCO₂ is similar at all flow rates while breathing through Hudson mask. Increase in RR can cause increase in FiCO₂ at lower flow rate, which is within physiological tolerance limits.

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Objectives: This study aimed to evaluate the relative efficacy of prophylactic intravenous (IV) clonidine and tramadol for control of intraoperative shivering following spinal anesthesia. Materials and Methods: After institutional ethical clearance, 142 patients were chosen from either gender, aged 20–60 years, physical status American Society of Anesthesiology Class I and II scheduled for elective infraumbilical surgery under spinal anesthesia. Patients were randomized into two groups: Group C (n = 71) received injection clonidine 50 μg) IV in 100 ml normal saline (NS) over 10 min and Group T (n = 71) received injection tramadol 50 mg IV. In 100 ml NS over 10 min after spinal anesthesia. Results: Incidence of shivering was not significant when compared between the two groups (P > 0.05). The axillary temperatures fell significantly in Group C from the baseline and remained at a significantly lower level up to 60 min after rescue drug was administered in patients who shivered. There was a similar fall in axillary temperature in Group T in patients having shivering, but the difference was not significant. When compared between the two groups among patients who shivered, the difference in fall of temperature was not significant. Side effects such as hypotension, bradycardia, and sedation were significantly more common in clonidine group, whereas nausea was significantly more common patients of tramadol group. Conclusion: Prophylactic administration of both tramadol and clonidine is effective for controlling shivering under spinal anesthesia. However, tramadol is better because of higher response rate, less sedation, and lesser hemodynamic alterations.

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Background: Epidural administration of neostigmine appears to be safe in the obstetric population. Recently, few studies have concluded 10 μg sufentanil to be an effective adjuvant with epidural neostigmine in providing labor analgesia. However, no study has evaluated the analgesic effect of epidural butorphanol with neostigmine for the same. Materials and Methods: The parturients were randomly allocated to one of the three study groups - Group A (n = 30) received butorphanol 1 mg and neostigmine 7 μg/kg. Group B (n = 30) received sufentanil 10 μg and neostigmine 7 μg/kg. Group C (n = 30) received neostigmine 7 μg/kg and 0.9% normal saline. Maternal hemodynamic parameters and fetal heart rate (FHR) were continuously monitored. The level of sensory and motor block, and visual analog scale (VAS) pain score were recorded at designated time points. In addition, the total duration of analgesia, duration of labor, mode of delivery, and any maternal or fetal adverse effects were also recorded. Statistical Analysis Used: A one-way analysis of variance (ANOVA) with post hoc Tukey's test was used to compare mean value among the three groups for age, height, weight, gestational age, and cervical dilatation. Repeated measure ANOVA was used to compare mean difference among the time points and also the trend among the various time points for hemodynamic parameters, VAS pain score, and FHR. For inter-group comparison among the groups, post hoc Tukey test was used. Results: There was a statistically significant longer effect of analgesic drug in Group B with respect to Group A and C (P < 0.001); however, the parturient in Group C had minimum duration of analgesia. Epidural neostigmine combined with sufentanil produces effective analgesia in early labor (VAS <30 within 10 min in 63.3% of parturient and within 15 min in 83.3% parturient) with average duration of 111.67 ± 24.51 min without motor block or other side effect in mother and fetus. No significant effect was observed in the duration of labor and mode of delivery in-between the two groups, and none of the patients in any group had any maternal or fetal side effects. Conclusion: Epidural combination of sufentanil with neostigmine provided better pain relief in terms of the total duration of analgesia and the reduction in VAS pain scores at various time points in the initial 30 min of epidural administration of drugs during the first stage of labor in parturient when compared to the epidural combination of butorphanol with neostigmine.

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Aims: To assess the patients' fears and their perception about regional anesthesia and to study the correlation between fears and perception and demographic profile. Design: A prospective cross-sectional survey on 150 patients scheduled for surgery under regional anesthesia (RA). Materials and Methods: The structured questionnaires composed of patients' demographic data and questions regarding patients' fears about RA. Questionnaires along with consent forms were sequentially distributed to patients. American Society of Anesthesiologists physical status Classes I and II patients aged between 18 and 80 years scheduled for surgery under RA at the preanesthesia clinics were included in the study. Statistical Analysis: Statistical analysis was done by calculating percentages using Chi-square test. Results: One hundred and fifty participants were studied, and their responses were analyzed. Overall, 75.3% (n = 113) patients had preoperative fear. Fear of pain during surgery, i.e., 49.3% (n = 56) and fear of needles 48.7% (n = 55) were the most common fears that were observed in the study population. Patients had less fear regarding nausea, vomiting, and headache. Patients' demographic details did not have a significant correlation with their fears except for gender, with women being more afraid (86.3% vs. 67.7% of men, P = 0.01). Six patients (4%) revealed dissatisfaction and 10 patients were neutral with RA. Ten patients (6.7%) opted for GA in the future and one patient opted for RA with sedation. Conclusion: There is a significant prevalence of fear for RA and its procedures which can affect the patients' decision and postoperative anxiety. The study replicated the high prevalence of anxiety and fear and has clinical implication of improving the education and specifically targeting the fears and anxiety to help the patients' better cope during and after the surgical procedure.

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Background: Spinal blockade provides excellent anesthesia for patients undergoing cesarean section. However, hypotension after spinal anesthesia is a common adverse effect that is commonly experienced in patients undergoing cesarean section. The aim of our study was to analyze if a simple technique like leg wrapping with elastic crepe bandage would be effective in controlling postspinal hypotension. Materials and Methods: Sixty full-term pregnant patients who were posted for cesarean section belonging to American Society of Anesthesiologists I and II were divided into two groups. Patients in Group W had their legs wrapped with elastic crepe bandage and in the other Group N, leg wrapping was not done. All the patients were preloaded with Ringer lactate at 10 ml/kg before the spinal anesthesia. The hemodynamic parameters were monitored every 3 min until the delivery of the baby and every 5 min until the end of surgery. If hypotension occurred, then along with crystalloid loading a bolus dose of mephentermine 6 mg was given intravenously. Statistical Analysis: Statistical software “Numbers version 3.6.1 (2566)” was used for statistical calculations. Results: Frequency of hypotension in Group W (10%) was significantly less compared to Group N (60%). Vasopressor requirement was significantly less in Group W (P = 0.009), which was highly significant. Conclusion: Wrapping of lower extremities was a simple, easy, and an effective method of decreasing episodes of hypotension and vasopressor requirement after spinal anesthesia in cesarean patients and needs to be practiced routinely.

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Background and Objectives: The laryngeal mask airway (LMA) ProSeal is most commonly used supraglottic airway device; it is routinely inserted by blind technique. Although blind insertion technique is most widely used, there are many techniques which are available such as priming the drain tube with a guiding instrument such as a suction catheter, a gum elastic bougie, a Flexi-Slip Stylet, direct laryngoscopy, and even a fiber-optic bronchoscope (FOB). The present study was undertaken to compare and assess the placement of LMA ProSeal using blind versus direct laryngoscopy techniques using FOB. Materials and Methods: A prospective randomized comparative study of 110 patients divided into two groups of 55 each as Group I (blind insertion) and Group II (direct laryngoscopic insertion) after satisfying the inclusion criteria. The anatomical position was assessed by flexible FOB and evaluated based on fiber-optic scoring system. Results: In the present study, demographic characteristics, vital parameters, Mallampati score, and Wilson's score were comparable in both the groups (P > 0.05). The fiber-optic score (FOS) 1 in Group II was 78.18% compared to 60% in Group I, but the difference was statistically not significant (P > 0.05). Furthermore, the mean FOS in Group II was slightly high (3.84 ± 0.87) compared to Group II (1.62 ± 0.87), but the difference was statistically not significant (P > 0.05). Further hemodynamic parameters (P > 0.05) and complications (P > 0.05) were comparable in both the groups. Conclusion: The LMA placement scoring was similar in both blind and direct laryngoscopic techniques. Blind insertion technique is a simpler, easier, and has stood the test of time.

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Transforaminal epidural steroid injection (TFESI) is a minimally invasive modality used to treat patients with lumbosacral radiculopathy secondary to prolapsed intervertebral disc or spinal canal stenosis. In this case report, we describe the management of a patient with chronic lumbosacral radiculopathy secondary to intervertebral disc herniation which was seen as a right paracentral disc protrusion at levels L4-L5, L5-S1 causing thecal sac indentation, effacement of the right lateral recess and right exiting nerve root impingement as was seen on the magnetic resonance image. Diffuse disc bulge at levels L4-L5 and L5-S1 caused thecal sac indentation with right neural foraminal narrowing. There was no evidence of associated facet joint arthropathy. Owing to the persistence of symptoms for >6 weeks despite medicines and an ESI through the caudal route 4 weeks back, anticipation of efficacy of TFESI with methylprednisolone using clonidine as an adjuvant in our patient was justifiable.

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